Jonathan Cheuk Hung Chan

Phacoemulsification versus combined phacotrabeculectomy in medically uncontrolled chronic angle closure glaucoma with cataracts.

OBJECTIVEnTo compare phacoemulsification alone versus combined phacotrabeculectomy in medically uncontrolled chronic angle closure glaucoma (CACG) with coexisting cataract.nnnDESIGNnProspective randomized clinical trial.nnnPARTICIPANTSnFifty-one medically uncontrolled CACG eyes with coexisting cataract of 51 patients.nnnINTERVENTIONnRecruited patients were randomized into group 1 (phacoemulsification alone) or group 2 (combined phacotrabeculectomy with adjunctive mitomycin C). Postoperatively, patients were reviewed every 3 months for 2 years.nnnMAIN OUTCOME MEASURESnIntraocular pressure (IOP) and requirement for topical glaucoma drugs.nnnRESULTSnTwenty-seven CACG eyes were randomized into group 1, and 24 CACG eyes were randomized into group 2. Combined phacotrabeculectomy resulted in lower mean postoperative IOP than phacoemulsification alone at 3 months (14.0 vs. 17.0 mmHg, P = 0.01), 15 months (13.2 vs. 15.4 mmHg, P = 0.02), and 18 months (13.6 vs. 15.9 mmHg, P = 0.01). Combined phacotrabeculectomy resulted in 1.25 fewer topical glaucoma drugs (P<0.001) in the 24-month postoperative period, compared with phacoemulsification alone. Combined surgery was associated with more postoperative complications (P<0.001) and more progression of optic neuropathy (P = 0.03), compared with phacoemulsification alone.nnnCONCLUSIONSnCombined phacotrabeculectomy with adjunctive mitomycin C is more effective than phacoemulsification alone in controlling IOP in medically uncontrolled CACG eyes with coexisting cataract. Combined phacotrabeculectomy is associated with more postoperative complications.

Systematic review and meta-analysis on the efficacy of selective laser trabeculoplasty in open-angle glaucoma

Selective laser trabeculoplasty (SLT) is a relatively new type of laser used in treating open-angle glaucoma (OAG) and is reported to be equally efficacious to a first-line medication and argon laser trabeculoplasty (ALT). We summarize available evidence for considering SLT as an alternative treatment in OAG through systematic review and meta-analysis. Among OAG patients who range from newly diagnosed to those on maximally tolerated medical therapy, SLT results in a 6.9-35.9% intraocular pressure (IOP) reduction. Complications are rare and include an IOP spike requiring surgery, persistent macular edema, and corneal haze and thinning. Meta-analysis of randomized, controlled trials shows that SLT is non-inferior to ALT and medication in IOP reduction and also in achieving treatment success. Number of medications reduction is similar between SLT and ALT. More robust evidence is needed to determine its efficacy as a repeated procedure.

Immediate argon laser peripheral iridoplasty (ALPI) as initial treatment for acute phacomorphic angle-closure (phacomorphic glaucoma) before cataract extraction: A preliminary study

PurposeTo study the safety and efficacy of immediate argon laser peripheral iridoplasty (ALPI) as initial treatment of acute phacomorphic angle-closure (phacomorphic glaucoma) before cataract extraction.MethodsIn all, 10 consecutive patients with acute phacomorphic angle-closure and intraocular pressure (IOP) ⩾40u2009mmHg were recruited into the study. Each patient received topical atropine (1%) and timolol (0.5%), and immediate ALPI as initial treatment. The IOP at 15, 30, 60, and 120u2009min, and then 1 day, after ALPI were documented by applanation tonometry. Systemic IOP-lowering drugs were only started if IOP remained above 40u2009mmHg at 2u2009h after ALPI. Cataract extraction was subsequently performed as definitive treatment.ResultsIn total, 10 patients (five male, five female), with a mean age±SD of 73.1±10.3 years were recruited. Mean duration of symptomatic attack was 128±232u2009h. After ALPI, the mean IOP was reduced from 56.1±12.5 to 45.3±14.5u2009mmHg at 15u2009min, 37.6±7.5u2009mmHg at 30u2009min, 34.2±9.7u2009mmHg at 60u2009min, 25.5±8.7u2009mmHg at 120u2009min, and 13.6±4.2u2009mmHg at 1 day. In one patient, systemic acetazolamide was administered, because the IOP remained above 40u2009mmHg at 2u2009h after ALPI. All 10 patients had uncomplicated cataract extraction performed within 4 days after ALPI. No complications from the laser procedure were encountered.ConclusionImmediate ALPI, replacing systemic antiglaucomatous medications, appeared to be safe and effective as first-line treatment of acute phacomorphic angle-closure.

To compare argon laser peripheral iridoplasty (ALPI) against systemic medications in treatment of acute primary angle-closure: mid-term results

PurposeTo compare the clinical outcome of argon laser peripheral iridoplasty (ALPI) against systemic medications in treatment of acute primary angle-closure (APAC).MethodsConsecutive patients with APAC were recruited and randomized to receive one of two treatment options: immediate ALPI or systemic acetazolamide±mannitol. All eyes were followed up for at least 6 months after laser iridotomy. Main outcome measures were intraocular pressure (IOP) and requirement for glaucoma medications.ResultsA total of 41 eyes (39 patients) were randomized into the ALPI group, and 38 eyes (32 patients) into the medical treatment group. There were no significant differences between the two groups in sex, age, presenting IOP, and duration of attack. Mean follow-up duration±SD was 15.7±5.8 months. There were no significant differences between the two groups in mean final IOP and requirement for glaucoma medications.ConclusionsThere were no statistically significant differences in mean IOP and requirement for glaucoma drugs between APAC eyes treated with ALPI and systemic medications.

Correlation of previous acute angle-closure attack with extent of synechial angle closure in chronic primary angle-closure glaucoma patients

AimTo document any correlation between previous acute angle-closure attack and the extent of synechial angle closure in chronic primary angle-closure glaucoma (PACG) patients.MethodsConsecutive cases of chronic PACG with patent peripheral iridotomy had gonioscopy performed. The extents of synechial angle closure of those chronic PACG eyes with previous documented acute angle-closure attack were compared to those eyes without such a history.ResultsA total of 102 chronic PACG eyes of 102 patients were recruited. Twenty-seven eyes (26.5%) had a previous documented acute angle closure, while 75 eyes (73.5%) did not. The mean extent of synechial angle closure ±1 SD was 307±68 degrees (range, 150–360 degrees) in those chronic PACG eyes with a history of previous acute angle closure, compared to 266±89 degrees (range, 90–360 degrees) in those chronic PACG eyes without such a history (P=0.03, Students t-test). There were no statistically significant differences between the two groups in age, LogMAR visual acuity, intraocular pressure (IOP), number of glaucoma eye drops, vertical cup-to-disk ratio, mean deviation or pattern SD in Humphrey automated perimetry, and anterior chamber depth (P>0.05).ConclusionPrevious acute angle-closure attack correlated with more extensive synechial angle closure in chronic PACG patients in this study.

Physical exercise and glaucoma: a review on the roles of physical exercise on intraocular pressure control, ocular blood flow regulation, neuroprotection and glaucoma-related mental health

The benefits of physical exercise on health and well‐being have been studied in a wide range of systemic and ocular diseases, including glaucoma, a progressive optic neuropathy characterized by accelerated apoptosis of retinal ganglion cells (RGCs). Elevated intraocular pressure (IOP) and insufficient ocular perfusion have been postulated to be the two main theories in glaucoma development and progression. The effects of exercise in these two aspects have been demonstrated by numerous researches. A review in 2009 focusing on these two theories concluded that exercise results in transient IOP reduction but an inconsistent elevation in ocular perfusion. However, the majority of the studies had been conducted in healthy subjects. Over the past decade, technological advancement has brought forth new and more detailed evidence regarding the effects of exercise. Moreover, the neuroprotective effect of exercise by upregulation of neurotrophin and enhancement of mitochondrial function has been a focus of interest. Apart from visual impairment, the mental health issues in patients with glaucoma, which include anxiety and depression, should also be addressed. In this review, we mainly focus on publications from the recent years, so as to provide a comprehensive review on the impact of physical exercise on IOP, ocular perfusion, neuroprotection and mental health in patients with glaucoma.

Development and pilot-testing of patient decision aid for use among Chinese patients with primary open-angle glaucoma

Background A patient decision aid (PDA) is a tool for shared decision making (SDM), which emphasises patient empowerment. It is useful in chronic diseases and when there are multiple, no best single treatment option. Although SDM is prevalent in Western countries, its use is limited in Chinese societies, where the adoption of a paternalistic approach is strong. Here, we report the development, acceptance and pilot test results of a PDA targeted at Chinese patients with primary open-angle glaucoma (POAG). Methods We developed a PDA designed for use in Chinese patients with POAG. Recruited subjects were given our PDA. Baseline evaluation included decision conflict scale (DCS), validated glaucoma adherence questionnaires and glaucoma knowledge questionnaire. Subjects were briefed through the PDA and instructed to read it that day. Three to four weeks later, follow-up questionnaire as described above were conducted with the addition of acceptance questionnaires. Results Data from 65 subjects were available. The PDA was well received among subjects. DCS improved from 48.9±20.4 at baseline to 34.3±20.3 during follow-up, with P<0.01. Validated medication adherence questionnaires and knowledge showed improvement from baseline, which was statistically significant. Conclusions The use of PDA among Chinese subjects with POAG demonstrated positive reception and acceptance. Evaluation of its initial effects shows improvement in DCS, medication adherence and glaucoma knowledge. The implementation of SDM and PDA among Chinese subjects with POAG is encouraged. Future studies with randomised design and later evaluation time points can further reveal the impacts of PDA among Chinese subjects with POAG.

Collagen crosslinking in the management of leaking cystic blebs: a prospective study

PurposeTo evaluate the effectiveness and safety of collagen crosslinking for leaking cystic blebs.MethodsA prospective study was conducted on subjects with cystic bleb leaks without indications for urgent surgical intervention. Collagen crosslinking with riboflavin 0.1xa0% and ultraviolet A irradiation for 30xa0min was applied to the cystic bleb surface in five patients. Subjects were followed up for at least 20xa0weeks (mean: 35.5 ± 11.5xa0weeks) to monitor the length of time to the cessation of bleb leak, as well as visual acuity, intraocular pressure, and the presence of adverse effects arising from the treatment.ResultsResults showed that a single session of collagen crosslinking was effective in stopping cystic bleb leak. In two of the five subjects, the bleb leak subsided 1xa0week post-treatment, in one patient after 2xa0weeks, and in the two more complicated cases, after 4xa0weeks. This effect was maintained for a mean period of 33.5 ± 10.2xa0weeks after bleb leak cessation. Treatment was effective even in patients with friable conjunctiva following multiple surgical interventions and severe leak, although a longer period was needed for resolution of the bleb leak. The intraocular pressure and visual acuity were largely stable before and after treatment. No side effects or complications arose from this treatment.ConclusionsWe recommend a trial of collagen crosslinking on leaking cystic blebs without indications for immediate surgical interventions. It is a relatively easy, non-invasive, pain-free, and potential repeatable procedure for treating leaking cystic blebs, with the aim of strengthening the underlying pathological conjunctiva.

ExPRESS Mini-Shunt as a Treatment Alternative for Medically Uncontrolled Steroid-Induced Glaucoma in a Pediatric Patient

This case report illustrates the use of ExPRESS mini-shunt in a pediatric glaucoma patient. We describe the management of steroid-induced glaucoma with ExPRESS mini-shunt in a 9-year-old boy with allergic keratoconjunctivitis. The intraocular pressure of both of his eyes was uncontrolled with medical and laser treatment. Both eyes were treated with ExPRESS mini-shunt and mitomycin-C. Transient overfiltration with postoperative hypotony occurred in both eyes and resolved after 2 weeks. One year postoperatively, intraocular pressure was maintained below 21 mm Hg without medication in 1 eye. Bleb needling with mitomycin-C was done to maintain filtration. The fellow eye received cataract extraction but developed bleb failure a few months afterwards. The intraocular pressure was controlled medically. To conclude, ExPRESS mini-shunt is a new surgical option in selected patients. Bleb failure developed after cataract extraction. Postoperative inflammation should be minimized. Patient selection, such as those with stable ocular condition, is important to increase surgical success.

Recurrent acute angle-closure attack due to plateau iris syndrome after cataract extraction with or without argon laser peripheral iridoplasty: a case report.

BackgroundWe describe two cases of recurrent acute angle-closure attack in patients with plateau iris syndrome after cataract extraction. Argon laser peripheral iridoplasty and cataract extraction have been used to reduce the occurrence of acute angle-closure attack in plateau iris syndrome although the risk cannot be completely eliminated. There is no consensus on the long term management of plateau iris syndrome. This is, as far as we know, the first case report of recurrent acute angle-closure attack in plateau iris syndrome after cataract extraction.Case presentationWe report two cases of recurrent acute angle-closure attack in 2 Chinese patients with plateau iris syndrome. The first patient was a 69xa0year-old woman who received bilateral argon laser peripheral iridoplasty and cataract extraction 2xa0years prior to the latest acute angle-closure with right eye intraocular pressure 48xa0mmHg. The attack was aborted medically. Peripheral iridotomy was patent and argon laser peripheral iridoplasty marks were mostly at peripheral 2/3 of the iris. Anterior segment optical coherence tomography confirmed bilateral plateau iris configuration. Use of long term pilocarpine or repeated argon laser peripheral iridoplasty to prevent recurrent angle-closure attack was discussed but she opted for observation. The second patient was a 64xa0year-old man presented with acute angle-closure after cataract extraction despite placement of laser peripheral iridotomy. Plateau iris syndrome was confirmed by anterior segment optical coherence tomography and he received argon laser peripheral iridoplasty.ConclusionsAcute angle-closure due to plateau iris syndrome can still occur despite previous cataract extraction and argon laser peripheral iridoplasty. These are the first reported cases of recurrent acute angle-closure attack due to plateau iris syndrome following cataract extraction, with or without previous argon laser peripheral iridoplasty. Repeated treatment with argon laser peripheral iridoplasty or pilocarpine could be considered although the long term efficacy is questionable. Argon laser peripheral iridoplasty should be applied as peripheral as possible so as to open up the drainage angle effectively.